Falling to Her Death: Long Term Care Facility Case Study

Elderly woman pictured from behind gazing out of window

Stacy L. Donnelly, R.N., B.S.N., Nursing and Nursing Home Expert

Plaintiff was 67 years old when she was admitted to a long-term healthcare and rehabilitation center in July 2019. At the time of admission, she had a history of dementia with behavioral disturbances, diabetes, seizures, hypertension, cardiovascular disease, gastroesophageal reflux disease, and encephalopathy. Plaintiff remained a resident at the center for the following three years. Between July 2019 and April 2022, she experienced approximately 26 falls.

According to the nursing staff’s assessment upon admission, Plaintiff was moderately cognitive impaired; she was unstable with ambulation and required the assistance of one person. She was a fall risk and required frequent reminders and redirection to ensure her safety. The nursing staff developed a care plan, which included that she required assistance with all her activities of daily living; frequent monitoring for optimal health; functioning interventions to address her psychosis, and a chair and bed alarm to reduce her risk of falling.

Beginning in November 2021, Plaintiff began to experience changes in her condition. Her two-year nursing assessment determined that she had experienced a marked decline in her lack of ability to ambulate. She now required a minimum of two people to assist her for all physical mobility, including bed mobility. Plaintiff was no longer able to ambulate and was bed/chair bound. She was assessed as always incontinent of bowel and bladder and unable to participate in a toileting program. She was severely cognitive impaired and unable to follow staff instructions. Despite these changes in her condition, the nursing staff failed to update her care plan. For example, she required two-person assistance for bed mobility; however, her care plan continued to state one-person assistance.

On April 19, 2022, Plaintiff was rolled off the edge of her bed while the Certified Nursing Assistant (CNA) changed the sheets. Despite requiring two persons’ assistance for her bed mobility, only one CNA was changing her bed. The bed was in a high position and the side rails were in the down position. The CNA rolled Plaintiff over on her side close to the edge of the bed and “pulled” on the sheet. As a result of these actions, Plaintiff rolled over the edge of the bed onto the floor. Her face struck the floor and she experienced an open area to the right side of her forehead with a hematoma.

911 was notified and Plaintiff was transferred to an acute care hospital for further evaluation and treatment. While at the acute care hospital, it was determined that she had a right frontal subdural hematoma and multiple facial fractures. Plaintiff was treated and discharged to another long-term care facility. Plaintiff was neurologically unresponsive and unable to move any extremities. Her eyes opened spontaneously, but the pupils did not move synchronously. Two weeks later, she became unresponsive. CPR was initiated and maintained until Emergency Medical Services arrived. She was again transferred to an acute care hospital, intubated, and ventilated. Plaintiff was pronounced dead one hour after arrival at the acute care hospital.

Expert retention was initiated to review the case and determine if the actions and inactions of the initial center and its staff met the standard of care for incident and accident prevention in the nursing and rehabilitation setting.

Upon review of the provided material, it was determined that throughout Plaintiff’s admission to the initial healthcare and rehabilitation center, there was an overall disregard for the standard of care in long-term care facilities. The standard of care is designed to prevent incidents and minimize risks through assessment and implementation of interventions, including evaluation of the interventions, and revision of them accordingly. By disregarding this, Plaintiff continued to fall until her death. The staff failed to meet the standards of care regarding assessments, care plan development and implementation, and incident and accident prevention. In addition, it was determined that the center failed to ensure their nursing staff was adequately trained and followed the standard of care for making an occupied bed.

Categories: Stacy L. Donnelly, R.N., B.S.N., Nursing and Nursing Home Expert

Tags: Elder | Long-term Care | Mobility Impairment | Registered Nurse | Rehabilitation | Standard of Care


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